Psychoanalytic/Psychodynamic Approaches to Personality Disorder 1
Psychoanalytic/Psychodynamic Approaches to Personality Disorder
Introduction
Historically, psychoanalytic thinking played a major role in identifying and defining
personality disorders (PDs), in particular, by recognizing PDs as a collection of diagnoses
that require a specific clinical approach. From Adolph Stern’s (1938) influential description
of his work with borderline patients, and the concept of the schizoid personality developed by
Ronald Fairbairn (1940/1952) and others (e.g., Guntrip, 1968), personality pathology has
acquired— and retained—a core position in psychoanalytic thinking. Psychoanalysis has
traditionally been focused on personality features associated with psychopathology, rather
than symptoms that arise from and perpetuate psychological problems (Clarkin, Fonagy, &
Gabbard, 2010). Now, at a time when psychodynamic treatment is just one part of a large,
diverse field of psychological interventions, PDs remains an area of pathology in which
psychodynamic thinking is influential and psychodynamic interventions have shown
effectiveness (Cristea et al., 2017; Leichsenring & Rabung, 2008).
We will begin this chapter with a brief overview of the psychodynamic approach to
PDs. Next, we will describe some of the major contemporary psychodynamic approaches to
PDs, their respective models, and the evidence for their effectiveness. Finally, we will
describe more recent developments in our thinking in relation to PD, and how connecting this
with theoretical developments in the area of a general psychopathology or “p” factor (Caspi
et al., 2014) has led us to reconsider our views in relation to the conceptualization of
personality disorders and their treatment.
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 2
The particular challenges presented by therapeutic work with individuals with PD
have required psychoanalysts to reconsider their work in creative ways – for example, the
limitations of a drive-focused, intrapsychic model in the context of working with severely
disturbed patients contributing to a shift towards a more interpersonal, object-relational and
developmental approach. This position of being forced to think differently—in terms of both
theory and technique—that inspired Stern’s (1938) paper on what at the time was termed the
“borderline group of neuroses,” its original meaning being here on the borderline between
neurosis and psychosis. The challenges of comorbidity, complexity, and chronicity associated
with PD continue to represent a significant challenge to how clinicians work, and have driven
ongoing discussions about the structure of psychopathology (Skodol et al., 2011).
Psychodynamic thinking has made some vital contributions to the ways in which we now
understand PD. However, the psychodynamic approach has also had its limitations; indeed, it
might be argued that one of the reasons PD has stimulated so much intellectual interest in the
psychoanalytic literature lies in the challenges that clinicians have faced when working with
people with a diagnosis of PD.
Different Psychoanalytic Traditions and Approaches to Personality Disorder
The Kleinian–Bionian Model
One of the models of PD that is perhaps most commonly held by psychoanalysts derives from
the work of Melanie Klein and Wilfred Bion. In essence, this model posits that personality
pathology is driven by the dominance of the paranoid–schizoid position, which causes the
individual to split objects into good (idealized, loving) and bad (persecutory, frightening,
hateful). The model also posits that psychological health depends on the individual being able
to retain (with relative stability) the depressive position, which is characterized by a more
balanced and developmentally mature capacity to recognize and tolerate the presence of both
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 3
bad and good together in one object, and to identify and correct one’s own tendency to split
representations of self and others in an unrealistic and distorting way.
In the classic Kleinian model, the tendency toward the paranoid–schizoid position is
considered to be primarily constitutional in origin, reflecting the individual’s overwhelming
destructive impulses—described as “envy” by Klein (1957)—being turned upon the object,
who provides love and sustenance. Bion elaborated this theory further by suggesting that
environmental processes might exacerbate this constitutional tendency. For Bion, the primary
environmental factor at work was the caregiver’s limited capacity for reverie, a concept used
by Bion (1967) to describe a caregiver’s ability to tolerate and contain their child’s primitive
and often difficult thoughts and feelings, and reflect them back to the child in a contained and
manageable form.
In relation to the symptoms and characteristics of PDs, this model proposes that
persecutory anxiety—that is, the sense of an overwhelming threat from a bad object—results
in a sense of fragmentation and even annihilation of the self. These symptoms are
characteristic of severe PD, and are particularly pertinent in the context of recent work
suggesting that borderline PD (BPD), which is perhaps most archetypically associated with
these symptoms, may capture the core of personality pathology or be representative of all
PDs (Sharp et al., 2015). In this model, chronic depression, such as manifests in depressive
PD but also in most if not all PDs, is considered to be an outcome of the individual being
unable to escape their fear of harming the loved object and thus repressing all aggression,
resulting in feelings of self-persecution. Narcissistic pathology is thus considered to be a
defense against envy and dependence; here, the individual makes use of the other in highly
destructive ways, leading to two possible forms of narcissism: thin-skinned, in which the
individual demands constant reassurance, and thick-skinned, in which the individual presents
a hostile, often arrogant and self-isolating stance in relation to others (Rosenfeld, 1971).
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 4
The work of the Kleinian school of writers has substantially enriched our
understanding of emotional development and psychological functioning, while the work of
Bion created a bridge between the two (previously separated) areas of cognitive development
and personality pathology. The influence of some of Bion’s thinking can be seen in recent
mentalizing approaches to PDs (described later in this chapter), for example, with parallels
being evident between the notion of the function of reverie (in Bion’s thinking) and the role
of the caregiver’s mirroring in helping the child tolerate and ultimately be able to think about
his/her own thoughts and feelings, and then others’ (in mentalizing theory). In contrast, there
are undoubtedly points of divergence between Kleinian thinking and more contemporary
work. One notable example derives from the fact that many Kleinians are skeptical about or
even somewhat hostile toward the place of empirical investigation in psychoanalysis, whereas
the pragmatic and intellectual value of the pursuit of empirical testing is a driving principle of
modern psychodynamic therapies. Furthermore, growing understanding of neuropsychology,
the role of genetics in mental health and disorder, and the complexity of gene–environment
interactions and epigenetics has left the classical Kleinian model appearing, by contrast,
prone to over-specification and excessively causally linear in relation to the links between
early experience and psychopathology in later life.
The British Object Relations Perspective
As mentioned in the Introduction, Ronald Fairbairn was one of the early leading
psychoanalytic figures in the field of PD. One of the key shifts, which was driven in the first
instance by Fairbairn, was a new focus on the individual’s need for the other and a
connection with the other per se, rather than the things (e.g., sustenance, libidinal
gratification) provided by others. This represented quite a radical change of emphasis in
psychoanalytic thinking from psychic structure to psychic content.
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 5
Fairbairn (1952b) proposed that the infant has a primary drive for contact—that is, to
create object relations. If this need for intimacy is not adequately met, the intolerable
experience of a rejecting or unsatisfying caregiver is defensively split and internalized
separate from the main, idealized representation of the caregiver and the self in relation to the
caregiver. According to this viewpoint, the co-existence of these incompatible
representations—the so-called schizoid condition—gives rise to psychological disorder
(Fairbairn, 1952b).
One of Fairbairn’s major contributions was the suggestion that severe early traumas
are stored in memories that are “frozen” or dissociated from a person’s central ego or
functional self (Fairbairn, 1944). The experience of privation, for example, makes the infant
view his/her love as bad and destructive, which in turn causes him/her to withdraw from
emotional contact with the outer world, and ultimately creates a highly disturbed experience
of external reality. Schizoid personality (Fairbairn, 1940/1952, 1952a) arises out of the
baby’s feeling that his/her love for the mother will destroy her and that it therefore has to be
inhibited, along with all intimacy. The ego is split and neither the other nor the self is
perceived as a whole person. These individuals hide their love and protect themselves from
the love of others. To this theory, Winnicott (1965a) added the idea of a falseness in self-
presentation that becomes truly maladaptive only in the context of an intimate interpersonal
relationship: this was where the concept of the “false self” originated. Guntrip (1968) further
added that the rejection by a hostile object leads to a “hunger” for objects that at the same
time are feared.
Winnicott (1965b) also argued that borderline patients employ a number of the same
defenses as psychotic patients. Winnicott (1960) notes that these patients have no sense that
others—including the therapist—have lives of their own. Such patients respond with intense
anger if their sense of omnipotence is threatened. These observations have been confirmed by
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 6
research showing that BPD patients have a specific deficit in mental-state awareness in the
context of attachment relationships (Fonagy & Target, 1996).
Winnicott, and object relational formulations more generally, did not completely
reject the role of constitutional factors in psychopathology, but they often exclusively
emphasized the role of the early environment. Such an emphasis is clearly incompatible with
the results of behavioral genetic studies that have since taken place (e.g., Plomin &
McGuffin, 2003). By contrast, the Freudian tradition showed greater respect for constitutional
factors and the role of genetics in, for example, symptom choice and vulnerability to
environmental stress. Research on the genetics of PD has in fact shown that PD is highly
heritable (Bornovalova, Hicks, Iacono, & McGue, 2009; Distel et al., 2008; Kendler et al.,
2008; Torgersen et al., 2008).
The major weakness of Winnicott’s theory—which the entire British object-relations
tradition displays—is its potentially somewhat naive reconstruction of infancy in the adult
mind, leading to often somewhat metaphorical descriptions that on the one hand are clinically
immensely useful, but fail to do justice to the complexity of psychological development. In
the face of the evidence (e.g. Rutter, Kim-Cohen, & Maughan, 2006), the argument for a
linear development from infancy to adulthood cannot be maintained. In fact, longitudinal
studies have suggested that personality is subject to reorganization throughout the complex
trajectory of development, based on significant positive and negative influences (Lyons-Ruth
& Jacobvitz, 2008; Lyons-Ruth, Yellin, Melnick, & Atwood, 2005).
Kohut and Self Psychology
Heinz Kohut’s central idea, developed most fully in the 1970s, was that an essential
developmental need for the infant, in the context of their helplessness and lack of physical
self-mastery, is the experience of an understanding, supportive caregiver (Kohut, 1971, 1977;
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 7
Kohut & Wolf, 1978). Kohut further proposed that this need for understanding—empathy
was a key term in his writing—persists throughout the lifespan. In the early years of life, the
caregiver’s support and empathy helps support the development of the child’s experience of
selfhood. This process of self formation is in the first instance supported by the caregiver
treating the child as a self in his/her own right, by identifying and recognizing the child’s
affects and helping the child to tolerate and think about them. Kohut describes the caregiver
as acting as a selfobject—the person in the environment who performs functions for the self.
The caregiver begins this process with the infant by providing empathic and mirroring
responses. The child’s experience of having his/her affects integrated and presented back to
him/her in this way allows the child to achieve a healthy developmental stage characterized
by a sense of their own grandiosity, which in turn acts as a defense against vulnerability. The
infant’s normal stage of “grandiosity” becomes, in healthy development, integrated with
more connected, realistic ambitions, via the idealized identification of a selfobject. The self-
cohesion provided by the selfobject’s empathic and supportive care enables the child to
develop the capacity for self-regulation and a stable sense of self esteem.
In Kohut’s model, psychopathology arises from the fear of losing one’s sense of who
one is. Deficiencies in the facilitating experiences provided by the selfobject can lead to a
primary psychic defect and an inadequately developed sense of self. According to this model,
PD is the result of a weakened sense of self that is susceptible to temporary fragmentation.
Kohut was particularly interested in narcissistic PD, and his thinking in relation to PDs
initially focused on narcissistic personality, which he interpreted as a developmental arrest at
the stage of the grandiose exhibitionistic self, which has not been tempered by integrative and
mirroring responses from the caregiver. This failure on the part of the caregiver causes an
arrest in the movement from the grandiose exhibitionistic self to realistic ambition, and from
the idealization of the parental imago to the formation of a healthier ego ideal. Repression of
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 8
the grandiose self leads, according to Kohut, to low self-esteem, vague depression, and lack
of initiative (Rosenfeld’s (1971) “thin-skinned” narcissism). When splitting dominates, the
grandiose self manifests as boastfulness, arrogance, and a dismissive attitude that is out of
touch with reality (Rosenfeld’s “thick-skinned” narcissism). Fundamentally, both forms of
narcissism are characterized by low self-esteem, hypersensitivity to criticism, and the need to
continue to be mirrored. According to this theory, violent behavior by narcissistic individuals
is triggered by a threat to the self that is experienced as a sense of shame, which generates an
overwhelming need to inflict injury on the shaming person and repair the narcissistic injury
(Gilligan, 1997). In this self-psychology model, BPD is conceptualized as the outcome of an
incapacity to retain access psychologically to soothing selfobjects; this creates an inner
emptiness and a failure of integrated self-organization that results in an overwhelming
annihilative panic when faced with the possibility of a threat to a relationship.
The Structural Object Relations Model
Otto Kernberg has been a highly influential thinker in the field of personality disorder. His
initial contribution was to succeed in integrating the ego psychology and object relations
traditions (see Kernberg, 1975, 1980a, 1980b, 1984, 1992). Kernberg’s theory positions
affect as the primary motivational system. Accordingly, the representation of the relationship
between self and object is driven by an “engine” of associated affects (Kernberg, 1982). This
triad of self, object, and affect (which Kernberg termed an object relations unit or dyad)
constitutes the basic building blocks of one’s personality.
Kernberg delineated a developmental trajectory that was strongly influenced by the
work of Jacobson and Mahler (Jacobson, 1953a, 1953b; Mahler, Pine, & Bergman, 1975), but
with less rigidly prescribed timing. According to this trajectory, in the very first stage (named
“infantile autism”, taking place in the first month or so of life) the infant does not
differentiate between the self and the object. During the second stage (“symbiosis”), good
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 9
and bad object representations are split by the ego to protect good images from the
destructive power of bad images. In the third year of life, the polarized good and bad
representations slowly become more integrated “separation-individuation”, enabling the
formation of total object representations and self-representations, which is the fourth stage –
“object constancy” (Kernberg, 1980b). If this integration fails, splitting remains the principal
mechanism of defense.
In PD, split, or part-object relations are formed under the impact of diffuse and
overwhelming affective states. These affects activate persecutory relations between the self
and object. From this perspective, BPD, for example, is characterized by: (1) ego weakness
(poor affect tolerance, impulse control, and little sublimatory capacity); (2) primitive
defenses, including splitting; (3) identity diffusion; (4) intact reality testing, but a propensity
to shift toward primary process thinking; and (5) pathological internalized object relations.
Influenced by Kleinian theory, Kernberg relates these features to the intensity of destructive
and aggressive affects and the relative weakness of the ego structures available to deal with
them.
Projective identification—which is pervasive in BPD—is seen as the by-product of an
absence of differentiation between self and object. Projective identification is seen as
resulting from massive primitive denial, ensuring that an individual can ignore his/her good
feelings towards the object, leaving bad feelings to dominate his/her consciousness. This
gives rise to the extreme and repeated oscillation between contradictory self concepts—as,
for example, victim or victimizer, dominant or submissive—that is characteristic of BPD
(Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989). Transient psychotic episodes
can occur because self and object representations are readily fused; however, because reality
testing remains adequate, these episodes do not persist. Self-destructiveness, self-injurious
behavior, and suicidal gestures are thought to coincide with intense phases of rage against the
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 10
object (Kernberg, 1987). Moreover, these gestures can establish control over the individual’s
environment because they provoke feelings of guilt. Self-injury is also seen as protecting the
individual from identity diffusion.
In Kernberg’s model, people with BPD have not achieved the developmental capacity
to integrate the good and bad self and object images into a single representation. Kernberg
leaves open to question the reasons why an individual may not achieve this stage; his model
does not rely on a simple environmental explanation centering around suboptimal early
experiences. Kernberg’s thinking is thus in agreement with emerging evidence about the
powerful role of genetic factors in BPD. There are other ways in which Kernberg’s work has
a richness and openness that keeps it from being superseded by contemporary developments.
One key element—which differentiates Kernberg’s work from the Kleinian background from
which it has emerged—is his engagement with empiricism: Kernberg’s commitment to
research has rendered both his theory and his therapeutic techniques testable. The
development of a systematic treatment approach together with his colleagues based on his
views, transference-focused psychotherapy (TFP; described later in this chapter), has
involved translating object relations theory into a clinical practice that is realistic and testable.
We would also suggest that Kernberg’s (1975) designation of borderline personality
organization (BPO) constitutes a creative response to the clinical dilemmas presented by the
failure of PDs, or of traditional Axis I diagnoses, to remain in their categorical “boxes” in the
lived experience of psychopathology. The BPO is characterized by identity diffusion caused
by “the failure of psychological integration resulting from the predominance of aggressive
internalized object relations over idealized ones” (Kernberg, Yeomans, Clarkin, & Levy,
2008, p. 603) and can be present in PDs, notably narcissistic and antisocial PD (particularly
in their more severe forms), as well as in some forms of depression. As mentioned above, a
recent study has suggested that BPD features may represent the core of personality pathology
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 11
(Sharp et al., 2015), the implications of which – that BPD criteria may be associated with a
general psychopathology severity factor – are intriguingly consistent with Kernberg’s
suggestion that BPO represents more than the narrow diagnostic category of BPD (Kernberg,
1967).
The Interpersonal–Relational Approach
The interpersonal–relational approach represents an area in which a psychoanalytic
contribution to PD has developed more recently. This approach has roots in the interpersonal
psychiatry school of Harry Stack Sullivan (1953), in particular, the view that subjectivity is
intrinsically interpersonal (Mitchell, 1988). In this respect, there is also an overlap with the
interpersonalist emphasis of Kohut’s self psychology, discussed earlier (Kohut, 1977).
Another area where interpersonal–relational and the object relations schools differ is that the
interpersonalist approach regards pathology as being embedded in relational matrixes,
whereas object relations tends to understand pathology in terms of an individual’s
developmental arrest.
According to the interpersonal model, the purpose of therapy is to help the patient
develop a more richly varied relational world (Mitchell, 1991). Because the interpersonal–
relational approach focuses on interpersonal patterns rather than psychiatric nosology, its
formulations tend to avoid labels such as “depression,” “personality disorder,” or
“narcissism”. The individual is seen not as having problems, but as having problematic
relationships. From this point of view, diagnostic labels reify interpersonal problems and
would take attention away from a therapeutic focus on the individual’s relationship
difficulties (e.g., Fairfield, Layton, & Stack, 2002).
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 12
Mentalizing Theory
A more recent psychoanalytic approach has emerged out of the confluence of
attachment theory and research on mentalizing and, more recently, contemporary
evolutionary thought. Mentalizing refers to one’s understanding of the behavior of both
oneself and others in terms of thoughts, feelings, wishes, and desires (Bateman & Fonagy,
2016). From this perspective, mental disorders in general can be viewed as the mind
misinterpreting its own experience of itself, and, by extension, its experience of others
(Bateman & Fonagy, 2010).
The mentalizing model was first developed in the framework of a large research
study, which found that, while the security of infant attachment was strongly predicted by the
parents’ security of attachment during pregnancy (Fonagy, Steele, Steele, Moran, & Higgitt,
1991), it was predicted even more strongly by the parents’ capacity to understand their
childhood relationships with their own parents in terms of states of mind, which can be best
described as mentalizing or reflective functioning (Fonagy et al., 1991). This work began a
program of empirical research, treatment development, and theoretical development focused
on the concept of mentalizing, which was postulated to emerge in the context of early
attachment relationships, as a fundamental determinant of self-organization and affect
regulation.
The mentalizing approach to BPD is fundamentally developmental. It focuses on
attachment disruptions and related impairments in mentalizing or the capacity to develop
second-order representations (i.e., representations of representations). The theory of
mentalizing postulates that one’s understanding of others depends on whether one’s own
mental states were adequately understood by caring, attentive, non-threatening adults in early
life. Problems with affect regulation, attentional control, and self-control stemming from
dysfunctional attachment relationships (Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004;
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 13
Lyons-Ruth et al., 2005; Sroufe, Egeland, Carlson, & Collins, 2005) are thus thought to be
mediated via a failure to develop a robust capacity to mentalize (Bateman & Fonagy, 2010).
This is not a straightforwardly environmental position; rather, the interaction between
genetic predisposition and early (and later) influences on the development of the capacity to
mentalize is thought to be of key importance in the development of BPD (Fonagy & Luyten,
2016). We therefore seek to situate these ideas within a broader developmental approach that
emphasizes the elements of interaction and diathesis–stress that are implicated in the
emergence of BPD.
In recent years, proponents of mentalizing theory have taken the argument a step
further to incorporate another important function of attachment relationships and, later on, the
broader sociocultural environment. This is the development of epistemic trust, that is, trust in
the authenticity and personal relevance of interpersonally transmitted knowledge. Epistemic
trust enables social learning and salutogenesis (the capacity to benefit from positive social
input) in an ever-changing social and cultural context (Fonagy, Luyten, & Allison, 2015).
This thinking is largely based on Csibra and Gergely’s (2009) theory of natural pedagogy.
Human beings are faced with a major “learnability” problem: they are born into a world that
is filled with objects and customs whose function or use is epistemically opaque (i.e., cannot
easily be deduced from their appearance).
Humans have evolved to both teach and learn new and relevant cultural information
rapidly. Human communication is specifically adapted to allow the transmission of
epistemically opaque information; the communication of such knowledge is enabled by an
epistemically trusting relationship. Epistemic trust allows the recipient of information being
conveyed to them to relax their natural epistemic vigilance—a phenomenon that is self-
protective and naturally occurring because it is not in anyone’s interest to believe everything
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 14
they are told indiscriminately. Relaxation of epistemic vigilance allows an individual to
accept that what they are being told matters to them (Sperber et al., 2010).
These views do not diminish the importance of attachment, but place theories
concerning the role of attachment in a somewhat different perspective. In terms of
psychopathology, we suggest that the most significant implication of the developmental triad
of attachment, mentalizing, and epistemic trust lies in the consequences of a breakdown in
epistemic trust. We suggest that many, if not all, types of psychopathology might be
characterized by temporary or permanent disruption of epistemic trust and the social learning
process it enables. It is here that attachment processes may be crucial.
An infant whose channels for learning about the social world have been disrupted—
that is, one whose social experiences with his/her caregivers have led to a breakdown in
epistemic trust—is left in a state of uncertainty and permanent epistemic vigilance. All
humans seek social knowledge, but when such reassurance and input is sought from others,
the content of their communication may be rejected, its meaning might be misunderstood, or
it may be (mis)interpreted as having hostile intent. From this perspective, many forms of
mental disorder might be considered manifestations of failures of social communication
arising from epistemic mistrust, epistemic hypervigilance, or outright epistemic freezing—a
complete inability to trust others as a source of knowledge about the world, which may be
characteristic of many individuals with marked histories of trauma and personality problems.
For example, someone who was traumatized in childhood has little reason to trust others and
will reject information from others that does not fit with their pre-existing beliefs. Therapists
may think of such people as “hard to reach,” but they are simply showing an adaptation to a
social environment in which information from attachment figures was likely to be misleading
or actively intended to be damaging. Hence, from this perspective, personality disorders are
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 15
not seen as disorders of personality, but as understandable adaptations to the environment,
even if they ultimately are counterproductive in terms of the functioning of the individual.
What is avoided in MBT is the use of complex descriptions of mental states and
behaviors that go beyond the patient’s ability to process while in states of high arousal. This
cautious approach to transference interpretation in MBT underlines a further aspect of
treatment, namely, the level of training required to deliver a treatment effectively without
iatrogenic effects. Dynamic therapies have often been criticized for their complexity and
difficulty to implement well without a long period of training. MBT was developed as a
research-based treatment to be implemented by generic mental health professionals, and this
may account for its perhaps over-cautious approach. MBT is concerned to avoid the possible
harmful effects of overzealous and clumsy transference interpretation. In other words,
transference interpretation is a complex technique that is not easily learned and may
specifically risk harm in patients with BPD if used inappropriately. Three days’ basic training
is provided and supervision is offered in the workplace as practitioners see patients for
treatment. Current results suggest that reasonable outcomes may be achievable within this
framework of mental health services without lengthy specialist training. This supports the
general utility of MBT.
Contemporary Psychodynamic Treatments ``
There is a growing evidence for a range of contemporary psychodynamic treatments (for a
review, see Leichsenring et al., 2015). Among the most researched are Transference-Focused
Therapy, Mentalization-Based Therapy and General Psychiatric Management, which we
discuss here.
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 16
Transference-Focused Psychotherapy
Transference-focused psychotherapy (TFP) was developed within an object relations
theoretical framework of borderline pathology. The conceptualization of the pathology in
TFP is not just based on the specific criteria of DSM-III (and more recent editions of the
DSM) but more broadly on the concept of BPO, with major structural deficits in
representations of self and others and the use of primitive defenses such as splitting (as
described earlier in this chapter). The basic assumption and starting point of TFP for BPD is
that typical self-object relations are activated in the therapeutic relationship. These can then
be subsequently worked-through using clarification, confrontation and interpretation,
particularly of the transference (hence the name of this treatment). The focus is specifically
on the split internal representations of self and others that are typical of BPD patients. For
instance, BPD patients often mentally represent others as either persecutors or idealized
rescuers, and their self representation is characterized by marked identity diffusion.
Treatment is focused on the patient’s present life rather than the past. The goals of treatment
are to reduce harmful actions by the patient and to develop a therapeutic relationship in which
the patient can come to reflect on his/her active and reactive perceptions of self and others,
including within the relationship with the therapist and with important others currently in the
patient’s life. Techniques of clarification, confrontation, and interpretation in the here-and-
now are used to expand the patient’s awareness of his/her conceptions of self and others,
especially in “hot,” conflictual situations when affect dysregulation is strong. The sequence
of clarification, confrontation, and interpretation aims to provide a context in which the
patient does not simply continue with his/her incoherent, contradictory sense of self and
others, but can reflect rather than react, and start to reappraise dominant themes of self–other
situations.
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 17
TFP is a manualized intervention (Clarkin, Yeomans, & Kernberg, 2006) that was
first developed as a highly structured, twice-weekly individual treatment for patients with
BPO. More recently, modified versions of TFP have been developed for work with patients
with narcissistic pathology and patients with more severe personality pathology (Yeomans &
Diamond, 2010).
The basic assumption and starting point of TFP for BPD is that typical self–object
relations are activated in the therapeutic relationship. These can subsequently be worked
through using a sequence of clarification, confrontation, and interpretation—particularly
interpretation of the transference (hence the name of this treatment). The focus is specifically
on the split internal representations of self and others typically held by individuals with BPD.
For instance, BPD patients often mentally represent others as either persecutors or idealized
rescuers, and their self-representation is characterized by marked identity diffusion. Hence, in
TFP the focus is on interpreting the content of mental representations.
TFP typically evolves through a series of stages. Initially, the focus is on contract
setting including agreement about boundaries of treatment and the role of the clinician in
managing self-destructive behaviors, and making an initial evaluation of the patient. These
initial steps provide a secure base from which to further explore the patient’s dominant object
relational patterns. Next, these dominant object relational patterns are investigated in detail
through the use of clarification, confrontation, and interpretation. This stage of treatment
focuses on how self–object patterns are activated in the transference relationship. Gradually,
these self–object patterns are clarified, and the patient is increasingly confronted with the
self–object poles, typical of BPD patients, that are lived out in the transference relationship
(e.g., victim and aggressor), and their oscillations between these poles—and this oscillation is
linked to their typical patterns of relating to others. These relational patterns are then
connected to the patient’s developmental history in a way that explores the potential
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 18
defensive functions of their self–object representations. This process is thought to decrease
the need for splitting, omnipotent control, and projective identification; to lead to more
differentiated and integrated representations of self and other; and to improve reflective
functioning (i.e., mentalizing) and affect regulation.
The therapeutic stance in TFP is more active than in “traditional” psychoanalytic
treatments, although there is an emphasis on technical neutrality and the use of the
countertransference to trace typical self–object dyads. As an example, if the therapist feels
terrorized by the patient’s relentless criticism of him/her, he/she uses this feeling in an
attempt to clarify, confront, and/or interpret the two poles of the underlying self–object dyad
and its defensive functions. The patient might “terrorize” the therapist (who then feels as if
he/she is the victim of a relentless perpetrator) because the patient fears that the therapist is
bored with him/her and therefore wants to end the treatment. By becoming a perpetrator out
of fear of becoming a victim, the patient reverses the roles: Instead of being a victim, he/she
becomes a perpetrator. In the later and more advanced stages of treatment, the therapist might
also interpret the patient’s underlying but disavowed wish to be cared for by a perfect,
idealized caregiver, a key feature of TFP.
Evidence Base
There is a growing evidence base for the effectiveness of TFP. A 1-year randomized clinical
trial (RCT) with a sample of 90 individuals with BPD compared the effectiveness of TFP,
dialectical behavior therapy (DBT), and psychodynamic supportive therapy (PST).
Significant improvements in anxiety, depression, global functioning, and social adjustment
were observed for each treatment group. In addition, TFP and DBT were associated with
significant reductions in suicidality, and TFP and SPT were associated with reductions in
impulsivity (Clarkin, Levy, Lenzenweger, & Kernberg, 2007). This study found that TFP
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 19
alone was associated with significant reductions in irritability and verbal and direct assault,
and with positive changes in levels of reflective functioning and attachment style (Levy et al.,
2006).
The effectiveness of TFP as a treatment for BPD was further evaluated in a
comparison with schema-focused therapy in a 3-year RCT. In this study, which had 88
participants, TFP was associated with improvements across all domains assessed, although
the dropout rate was higher for TFP, and SFT was superior to TFP with respect to reduction
in BPD manifestations, general psychopathologic dysfunction, and change in SFT/TFP
personality concepts (Giesen-Bloo et al., 2006). A more recent study of TFP versus treatment
by experienced community psychotherapists, with a sample of 104 women with BPD, found
that TFP was significantly more effective in terms of BPD symptoms, psychosocial
functioning, personality organization, rates of suicide attempts, and psychiatric in-patient
admissions. TFP also had a significantly lower participant dropout rate (Doering et al., 2010).
In the TFP condition, there were significant improvements in mentalizing, and improvements
in reflective function were significantly correlated with improvements in personality
organization (Fischer-Kern et al., 2015).
Mentalization-Based Treatment
Mentalization-based treatment (MBT) is, essentially, a therapy that places mentalizing
processes at the center of the therapy process, rather than directly focusing on object
representations. At the core of MBT is the idea that the therapy works through the therapist
establishing an enduring attachment relationship with the patient, while continuously
stimulating mentalizing in the patient. The objective is for the patient to discover more about
how they think and feel about themselves and others, how these thoughts and feelings
influence their behavior, and how distortions in understanding themselves and others lead to
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 20
maladaptive actions—albeit ones intended to maintain stability and manage
incomprehensible feelings.
MBT was originally developed in the 1990s for the treatment of adults with BPD in a
partial (day) hospital setting (Bateman & Fonagy, 1999). MBT has subsequently evolved into
a more widely applied approach that has been used in work with patients with a range of PDs
(most notably antisocial PD) and other mental health disorders (e.g., eating disorders,
depression) in a range of treatment settings, and with adolescents as well as adults. As such, a
program of MBT does necessarily always have the same shape. However, the structure of
treatment is broadly replicated across the different contexts in which it is applied. The
original outpatient program involved patients attending 5 days per week for a maximum
period of 18–24 months (Bateman, 2005; Bateman & Fonagy, 1999). For the treatment of
PDs, MBT now most commonly consists of an 18-month outpatient program comprising
weekly individual sessions of 50 minutes and weekly group sessions of 75 minutes (Bateman
& Fonagy, 2009).
The structure of MBT for PDs normally consists of three phases. The first comprises
an assessment of the patient’s mentalizing capacities and personality function, contracting
and engaging the patient in treatment, and identifying any problems that might interfere with
treatment. Specific elements of this phase include giving a diagnosis, providing
psychoeducation, establishing a hierarchy of therapeutic aims, stabilizing the patient’s social
and behavioral problems, reviewing the patient’s medication and defining a pathway of
actions to be taken in the event of a crisis.
The second phase consists initially of individual therapy, followed by the introduction
of group therapy alongside the individual sessions. There is a fairly firm insistence in MBT
that consistent attendance of both the individual and group sessions is necessary in order for
the patient to be able to continue on the program, and that simply attending for individual
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 21
treatment (as is most often the case for patients who do not attend all of their sessions) is not
an option. During this second phase of the program, the main work of seeking to develop
more robust mentalizing skills is undertaken.
The final phase of MBT, which normally begins at 12 months of treatment when there
is a further 6 months remaining, involves preparing the patient for the end of treatment.
Typically, at this point, many of the most obvious and worrying aspects of BPD
symptomatology, such as impulsive behavior and affective instability, have diminished.
However, patients may still struggle with interpersonal and social/vocational functioning, and
may experience considerable difficulty in their general functioning and ability to form
constructive relationships. Therefore, assuming that symptomatic and behavioral problems
are well controlled, this final phase focuses on the interpersonal and social aspects of
functioning. The final phase must also involve consideration of the end of treatment and the
feelings of separation and loss that might be associated with such an ending. This is not just
about facilitating the end of treatment; working on these issues may be of great value in
consolidating the gains made in therapy. A final component of this phase is to collaboratively
develop with the patient a follow-up treatment plan. There is no prescribed follow-up
treatment in MBT, but this plan may, depending on the patient’s needs and preferences,
consist of couples therapy, group therapy, outpatient maintenance treatment, or
educational/vocational counseling connected with returning to education or work.
The fundamental aim of MBT is to re-establish mentalizing when it is lost and
maintain mentalizing when it is present. The MBT clinician focuses on the patient’s
subjective sense of self. To do so, they need to (1) identify and work with the patient’s
mentalizing capacities, (2) represent internal states in themselves and in the patient, (3) focus
on these internal states, and (4) sustain this focus in the face of constant challenges from the
patient over a significant period of time. To achieve this level of focus, mentalizing
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 22
techniques need to be (1) offered in the context of an attachment relationship, (2) consistently
applied over time, and (3) used to reinforce the therapist’s capacity to retain mental closeness
with the patient.
In agreement with the mentalization-based theoretical model of BPD described
earlier, MBT is aimed at gently expanding the patient’s mentalizing capacities while paying
attention to the stability of his/her sense of self, and managing the interpersonal intimacy
between therapist and patient and helping the patient maintain a level of arousal that ensures
his/her engagement in the process. The well managed (i.e., not too intense and not too
detached) attachment relationship between the patient and therapist optimizes the level of
arousal. In MBT, the aim and the actual outcome of an intervention on the patient’s
immediate emotional and cognitive state is thought to be more important than the insight
gained from interpreting particular defenses or understanding aspects of the transference
relationship, although of course such insights emerge during treatment. The therapist assesses
and attends to breaks in mentalizing, which are assumed to represent a break in the patient’s
continuity of experience of their mind. When these occur, the therapist’s task is to “rewind”
to the moment before the break in subjective continuity occurred. The therapist then explores
the current emotional context in the session by identifying the momentary affective state
between patient and therapist. Identifying the therapist’s own contribution to the break in
mentalizing—and showing humility in relation to this and taking responsibility for it—is
often key.
As should be clear, the focus is on the process rather than the content. At the heart of
MBT practice is the concept of the therapist’s mentalizing stance. Typically, the mentalizing
stance includes the following components: (1) humility deriving from a sense of “not
knowing”; (2) patience in taking time to identify differences in perspectives; (3) explicit
legitimizing and accepting of different perspectives; (4) active questioning of the patient
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 23
about his/her experience, asking for detailed descriptions of experience (“what” questions)
rather than explanations (“why” questions); and (5) careful eschewing of the need to “help”
the patient to understand what makes no sense (e.g., by saying explicitly that something is
unclear). This last aspect in particular sets MBT apart from predominantly insight-oriented
therapies. The MBT therapist is there to help the patient learn about the complexities of the
patient’s thoughts and feelings about him/herself and others, how that relates to his/her
responses, and how “errors” in understanding him/herself and others lead to actions. It is not
for the therapist to “tell” the patient about how he/she feels, what he/she thinks, how he/she
should behave, or what the underlying conscious or unconscious reasons for his/her
difficulties are.
The key features that facilitate the therapeutic aim of MBT—the recovery of more
robust mentalizing—may be seen in terms of the following structural properties of the
treatment: (1) an extensive effort to maintain engagement in treatment (validation in
conjunction with emphasis on the need to address behaviors that interfere with therapy such
as alcohol or substance abuse or self harm); (2) utilization of a model of pathology that is
explained to the patient; (3) an active stance by the therapist, that is, an explicit intent to
validate and demonstrate empathy, generate a strong attachment relationship, and create
epistemic trust (a sense in the patient that the therapist’s views of the world can be trusted as
relevant to the patient); (4) a focus on emotion processing and the connection between actions
and feelings (e.g., how suicidal wishes link to feelings of abandonment); (5) a genuine
inquiry into patients’ mental states (behavioral analysis, clarification, confrontation); (6)
adoption of a structure of treatment that suggests increased activity, proactivity, and self-
agency (avoiding the use of an expert stance, and encouraging collaboration with the patient
and a “sit side-by-side” therapeutic attitude); (7) acceptance of a structure for the nature of
the relationship between patient and therapist is defined that is robust to distortions by the
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 24
patient’s emotional dysregulation (i.e., what is crucial is that the therapist is able to think
without having to withdraw from exchanges or fall back on “mindless” rules established by
prior contract or precedent); (8) therapeutic work is supported by the structure provided by a
manual, and adherence to that structure is sustained by supervision; (9) the therapist and the
entire therapeutic milieu reflect commitment to the mentalization-based approach and
underscore the importance the therapist attaches to the patient’s thoughts and feelings.
Enabling mentalizing and developing epistemic trust and the capacity for salutogenesis that
results from the restoration of these capacities, is perhaps a component of other effective
therapies for BPD, as we shall discuss more fully below.
Evidence Base
There is an ample evidence base for MBT, beginning with an RCT of an 18-month program
for 44 patients with BPD in a partial hospital setting (Bateman & Fonagy, 1999, 2001), which
found significant and enduring changes in mood states and interpersonal functioning.
Outcome measures included frequency of suicide attempts and acts of self-injury, number
and duration of in-patient admissions, service use, and self-reported depression, anxiety,
general symptom distress, interpersonal function, and social adjustment. Relative to treatment
as usual (TAU), the benefits were large, with a number needed to treat of approximately two.
The benefits were also observed to increase during the follow-up period of 18 months. The
day hospital MBT program has been investigated in a series of outcome studies, culminating in
an 8-year follow-up study (Bateman & Fonagy, 2008), the longest follow-up of treatment for
BPD conducted to date. Compared with TAU, MBT was associated with fewer suicide
attempts, emergency room visits, in-patient admissions, less medication and outpatient
treatment utilization, and lower impulsivity. At follow-up, far fewer patients in the MBT group
than the TAU group met criteria for BPD (13% vs. 87%). In addition to symptomatic
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 25
improvement, patients in the MBT group showed greater improvement in interpersonal and
occupational functioning.
Similarly in an RCT involving 134 patients, an intensive outpatient MBT program
proved more effective than structured clinical management for BPD at the end of the 18-month
treatment period (Bateman & Fonagy, 2009), particularly for patients with more than two PD
diagnoses (Bateman & Fonagy, 2013). Compared with TAU, the outpatient treatment resulted
in lower rates of suicidal behavior and non-suicidal self-injury as well as fewer hospitalizations.
The MBT group also showed improved social adjustment, coupled with diminished depression,
symptom distress, and interpersonal distress.
Elsewhere, an RCT in Denmark investigating the efficacy of MBT versus a less
intensive, manualized supportive group therapy program in patients diagnosed with BPD
found that MBT was superior to the comparison treatment on clinician-rated Global
Assessment of Functioning (Jørgensen et al., 2013). These results were sustained 18 months
later in a naturalistic follow-up (Jørgensen et al., 2014). In another study from Denmark
(Petersen et al., 2010), a cohort of patients treated with partial hospitalization followed by
group MBT showed significant improvements after treatment of on average 2 years on a
range of measures, including Global Assessment of Functioning, hospitalizations, and
vocational status, with further improvement at 2-year follow-up.
A naturalistic study by Bales et al. (2012) in the Netherlands investigated the
effectiveness of an 18-month manualized program of MBT in 45 patients with severe BPD.
Treatment was associated with significant positive change in symptom distress, social and
interpersonal functioning, and personality pathology and functioning, with moderate to large
effect sizes. However, this study is limited by the lack of a control group. Another study by
the same group (Bales et al., 2015) used propensity score matching to ascertain the best
matches for 29 MBT patients from within a larger (n=175) group who received other
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 26
specialized psychotherapeutic treatments. Generally moderate improvement across all
domains was found in the group receiving other psychotherapeutic treatment, while effect
sizes were consistently large for MBT, with Cohen’s d for reduction in psychiatric symptoms
of −1.06 and −1.42 at 18 and 36 months, respectively, and Cohen’s ds ranging from 0.81 to
2.08 for improvement in areas of personality functioning. However, between-condition
differences in effects should be viewed with caution because of the non-randomized study
design and the variations in treatment dose received by participants.
More recently, research has been undertaken to assess the effectiveness of MBT in
different diagnostic contexts. An RCT in the UK (Robinson et al., 2016) compared MBT for
eating disorders (MBT-ED) against specialist supportive clinical management for patients
with eating disorders and symptoms of BPD. There was a high dropout rate in this study
(only 15 of the 68 participants eligible for randomization (22%) completed the 18-month
follow-up), making results difficult to interpret, but MBT-ED was associated with greater
reductions in Shape Concern and Weight Concern on the Eating Disorder Examination,
relative to the control treatment. Another recent RCT of MBT for individuals with comorbid
antisocial PD and BPD found that MBT was effective in reducing anger, hostility, paranoia,
and frequency of self-injurious behavior and suicide attempts, and brought about
improvements in negative mood, general psychiatric symptoms, interpersonal problems, and
social adjustment (Bateman, O'Connell, Lorenzini, Gardner, & Fonagy, 2016).
Conclusion: Going Forward
Recent meta-analyses have suggested that there are now several forms of psychological
therapy for BPD and other types of PDs that are of some value (Cristea et al., 2017;
Leichsenring, Leibing, Kruse, New, & Leweke, 2011; Stoffers et al., 2012). What is more,
these meta-analyses have suggested that there is little substantial difference in effectiveness
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 27
between specialized and non-specialized treatment approaches, at least in the treatment of
BPD (Cristea et al., 2017). Meta-analytic findings so far thus clearly suggest that there is no
one single treatment method—psychodynamic or otherwise—that can claim exclusive
therapeutic potency.
These findings are congruent with the recent emphasis in psychoanalytic approaches
to PD on epistemic trust —that psychopathology is a form of disordered social cognition,
perpetuated by the obstacles to communication that these social cognitive difficulties create.
What is called “psychotherapy” may simply be, from this perspective, a recent variant of an
activity that has been part of the repertoire of communicative behavior for a very long time—
turning to other people’s thoughts to help us make sense of our own. For individuals with
PDs, the loss of epistemic trust is a powerful obstacle to this process of beneficially accessing
other people’s minds in order to reinstate the capacity to tolerate and understand one’s own
mind.
This may lead to a new view on the mechanisms of change in the treatment of
individuals with personality problems, and particularly with regard to their so-called “hard-
to-reach” or “treatment-resistant” character (Fonagy et al., 2015).
Effective modes of psychological treatment for PDs that now exist all involve, in our
opinion, three distinct processes of communication that cumulatively render them effective
(Fonagy & Luyten, 2016):
Communication System 1: The teaching and learning of content
The different therapeutic schools belong to this system. They may be effective
primarily because they involve the therapist conveying to the patient a model for
understanding the mind that the patient can understand, as it includes a convincing
recognition and identification of his/her own state. This feeling of being recognized
and understood may in itself lower the patient’s epistemic vigilance.
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 28
Communication System 2: The re-emergence of robust mentalizing
When the patient is once again open to social communication in contexts that had
previously been marred by epistemic hypervigilance, he/she begins to show increased
interest in the therapist’s mind and the therapist’s use of thoughts and feelings, which
stimulates and strengthens the patient’s capacity for mentalizing. Improvements in
mentalizing or social cognition may thus be a common factor in different
interventions.
Communication System 3: The re-emergence of social learning
The relaxation of the patient’s epistemic hypervigilance achieved via the first two
systems of communication enables the patient to become more open to social
learning. This allows the patient to apply his/her new mentalizing and communicative
capabilities to wider social encounters, outside the consulting room. This final part of
the process depends upon the patient having a sufficiently benign social environment
to allow him/her to gain the necessary experiences to validate and bolster his/her
improved mentalizing, and to continue to facilitate the relaxation of epistemic
mistrust, in the wider social world.
These three systems of communication, we suggest, provide a framework for investigating
the effectiveness of psychotherapies. Beyond the therapeutic treatment itself, the model also
directs attention to the social environment, and to interventions that may directly target
environmental factors that could contribute to the origin and maintenance of
psychopathology, and those factors that could have the potential to support recovery and the
patient’s capacity to benefit from benign aspects of his/her environment. This widening of the
view of what determines therapeutic outcomes to include the social environment beyond the
consulting room represents a challenge to the potential omnipotence of all psychological
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 29
therapies, but perhaps more archetypally, to the therapeutic primacy of the psychoanalytic
relationship.
What role do these speculations leave for the psychoanalytic approach in particular?
We suggest that its future may lie in helping us make sense of how we think about PD, how
we conceptualize psychopathology, and what it is that makes treatment effective. This is not
simply an intellectual exercise: traditional diagnostic categories, and the treatments
accordingly assigned to them, are increasingly viewed as failing to recognize the complexity
of mental health presentations throughout the life span (Skodol et al., 2011). These issues are
particularly pertinent in the field of PD, in which recurrence, comorbidity, and complexity are
very common (O'Connor, 2005; O'Connor & Dyce, 1998). The psychoanalytic approach
encompasses a uniquely sophisticated model of the mind, which, if applied with intellectual
openness rather than rigid orthodoxy, can tolerate the categorical complexity of personality-
disordered states.
Psychoanalytic/Psychodynamic Approaches to Personality Disorder 30
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